Neurology Flashcards
1
Q
Causes of blackouts - 7
A
Vasovagal (neurocardiogenic) syncope
Situational syncope ie cough or micturition
Carotid sinus syncope
Epilepsy
Stokes-Adams sacks - transient arrhythmia
Hypoglycaemia
Orthostatic hypotension
2
Q
What is vasovagal syncope, onset and what happens during
A
Reflex bradycardia with or without peripheral vasodilation provoked by emotion, pain, fear, standing
Onset over seconds, preceded by nausea, pallor, sweating, closing in of visual fields
Unconscious for around 2 mins, may have brief clonic jerking of limbs (reflex anoxic)
May have urinary incontinence
Post ictal recovery rapid
3
Q
Differentiate reflex anoxic jerks in vasovagal from epilepsy - 4
A
No stiffening
No tonic - clonic sequence
No tongue biting
Rapid post-ictal recovery
4
Q
What is situation syncope
A
Sx same as vasovagal - preceding nausea, pallor, sweating, unconscious +- reflex anoxic myoclonic jerks, urinary incontinence
Caused by cough, effort (exercise, from cardiac origin ie aortic stenosis) or micturition (mostly men at night)
5
Q
What is carotid sinus syncope
A
Hypersensitive baroreceptors cause excessive reflex bradycardia +- vasodilatation on minimal stimulation eg head turning
6
Q
Features of LOC suggestive of epilepsy - 8
A
When asleep or lying down Aura Identifiable trigger Altered breathing, cyanosis Tonic-clonic movements Tongue biting Urinary incontinencce Prolonged post-ictal drowsiness, confusion, amnesia and transient focal paralysis
7
Q
What is syncope related to arrhythmia and features, and how often?
A
Stokes-Adams attacks - transient arrhythmia eg bradycardia from complete heart block, reduces CO and causes LOC
Often with no warning except palpitations
Pale, slow/absent pulse
Recovery within seconds, with flushing, pulse speeding up and consciousness returns
Can be several times a day and in any posture
8
Q
What is a cause of sudden fall with no LOC in the elderly - 3
A
Drop attacks - sudden weakness in legs, generally older women
Benign and spontaneously resolves after a few attacks
Cataplexy - triggered by emotion
Hydrocephalus - may not be able to get up for hours
9
Q
What makes orthostatic hypertension more likely? - 4
A
Inadequate vasomotor reflexes: Elderly Autonomic neuropathy Antihypertensives, overdiuresis Multi system atrophy
10
Q
Features of anxiety attack - 7
A
Hyperventilation Tremor Sweating Tachycardia Paraesthesia Light headed ness No LOC
11
Q
What exams to do for LOC - 3
A
Cardiovascular
Neurological
BP standing and lying
12
Q
Investigation for LOC
A
ECG +-24h for arrhythmia, long qt; echo UE, FBC, glucose Tilt table test EEG, sleep eeg CT/MRI brain PaCO2 - low = hyperventilation
13
Q
What is vertigo?
A
Illusion of movement, often rotator, of patient or surroundings
Always worsened by movement
14
Q
Associated sx with vertigo - 4
A
Difficulty walking or standing
Relief on sitting still or lying
NV, pallor, sweating
Hearing loss or tinnitus = labyrinth or CN8 involvement
15
Q
Anatomical locations of causes of vertigo - 4 most common
A
Labyrinth
Vestibular nerve
Vestibular nuclei
Central connections
16
Q
7 common causes of vertigo
A
- Benign paroxysmal vertigo due to canalolithiasis
- Acute labyrinthitis/vestibular neuronitis
- Ménière’s disease
- Ototoxicity - aminoglycosides, loop diuretics, cisplatin - also dizziness
- Vestibular schwannoma (also known as acoustic neuroma incorrectly)
- Traumatic damage of patrons temporal bone or cerebello-pontine angle affecting auditory nerve
- Herpes zoster - eruption of external auditory meatus
17
Q
Features of BPV and treatment
A
Canalolithiasis - debris in semicircular canal disturbed by head movement, resettles causing vertigo for a few seconds after movement
Nystagmus on performing Hallpike manoeuvre = diagnostic
Cleared by Epley manoeuvre
18
Q
What is acute labyrinthitis and features
A
Abrupt onset of severe vertigo, NV +- prostration
No deafness or tinnitus
Caused by virus or vascular lesion
Severe vertigo subsides in days, complete recovery in 3-4w
Treat = reassure, sedate
19
Q
What is Ménière’s disease, 3 features and treatment
A
Endolymphatic hydrops causing 1. recurrent attacks of vertigo lasting >20m +- nausea, 2. fluctuating sensorineural hearing loss (may be permanent), 3. Tinnitus with sense or aural fullness
Treat with bed rest and reassurance, and antihistamine if prolonged
20
Q
What causes ototoxicity
A
Aminoglycosides
Loop diuretics
Cisplatin
21
Q
Features of vestibular schwannoma
A
Unilateral hearing loss Vertigo occurs later Progresses to affect ipsilateral CN5, 6, 9, 10 and ipsilateral cerebellar signs Late = signs of RICP A type of cerebello-pontine angle tumour
22
Q
How does traumatic damage cause vertigo
A
To petrous temporal bone or cerebello-pontine angle, affects auditory nerve, causing vertigo, deafness, tinnitus
23
Q
What infection can cause vertigo and what else does it cause?
A
Herpes zoster - herpetic eruption of external auditory meatus, causes facial palsy +- deafness, tinnitus, vertigo = Ramsay Hunt syndrome
24
Q
What causes related to the brain stem, cerebellum and cerebello-pontine angle can cause vertigo and what other sx are there
A
Also nystagmus and CN lesions MS Stroke/TIA Haemorrhage Migraine Vestibular schwannoma
25
Management and progress of vestibular schwannoma
Serial MRIs for a few years to predict growth
30% don’t progress, 50% grow slowly and 20% grow quickly
Malignancy rare
Microsurgical removal can cause damage to CN7
26
Causes of conductive deafness and finding on tuning fork test
Wax, otosclerosis, otitis media or glue ear
Weber - localises to ear with conductive loss
Rinne = negative = bone conduction louder than air conduction
27
Causes of sensorineural deafness - 3 chronic 8 acute
```
Chronic
- accumulated environmental noise toxicity
- presbyacusis (loss of higher frequency sounds from age 30)
- inherited disorders
Acute
- V vasculitis
- V stroke
- I mumps
- I TB
- T noise exposure
- A MS
- I toxin eg gentamicin
- N acoustic neuroma
```
28
Tests for sudden sensorineural deafness
```
ESR, FBC, LFT
Viral titres and TB
Evoked response audiometry
CXR
MRI
Lymph node and nasopharyngeal biopsy for malignancy and TB culture
```
29
Result of tuning fork tests for sensorineural hearing loss
Tuning fork = 512hz
SNAC-RIP
Sensorineural loss and Normal ears, Air Conduction better - Rinne Is Positive
Weber localises sound to contralateral ear from affected ear in sensorineural loss
30
Causes of tinnitus
Focal hyper-excitability in auditory cortex
Viral
Presbyacusis, Meniere’s, hearing loss
Excess noise, wax
Head injury
Septic otitis media
Hypertension
Drugs - aspirin, loop diuretic, aminoglycosides
Psychological - diverse
Pulsatile = carotid artery stenosis or dissection, AV fistulae
31
Investigate tinnitus
Pulsatile may be audible with stethoscope
MRI
If unilateral, exclude vestibular schwannoma
32
Complications of tinnitus
Depression, insomnia
33
Manage tinnitus
Psychological support, reassure
Hypnotics at night
White noise through noise generator like a hearing aid
Cochlear nerve section if disabling - causes deafness
Repetitive transcranial magnetic stimulation of auditory cortex
34
Key questions for weak legs - 6
1. Onset gradual or sudden
2. Progressing at what rate
3. Spastic or flaccid legs
4. Sensory loss. Level = spinal cord disease
5. Loss of sphincter control
6. Signs of infection - spinal tenderness, raised WCC, eg extradural abscess
35
Sx in progressive weakness
Spinal or root pain first
Then leg weakness and sensory loss
- arm weakness is less severe as suggests cervical cord lesion
Bladder sphincter involvement is late = hesitancy, frequency then painless retention (neurogenic)
Signs:
- motor, reflex and sensory level - normal above, LMN signs at level, UMN signs below level
- tone and reflexes are usually reduced in acute cord compression
36
Causes of progressive weakness due to cord compression - 7
Most common = secondary malignancy - breast, lung, prostate, thyroid, kidney - in spine
Infection - epidural abscess
Cervical disc prolapse, atlanto-axial subluxation
Haematoma (warfarin)
Intrinsic cord tumour, myeloma
37
Differentials for progressive weakness (not due to cord compression)
Transverse myelitis
MS, Guillaun-Barre
Spinal artery thrombosis, dissecting aneurysm
Trauma
38
Investigations for cord compression
MRI sine
Biopsy or surgical exploration to investigate mass
CXR for primary lung malignancy, secondaries or TB
Screening bloods - FBC, ESR, B12, LFTs, syphilis, UE, PSA
Serum electrophoresis
39
treatment cord compression
Dexamethasone IV 4mg/6h if malignancy then consider C/RT, decompressive laminectomy
Surgical decompression and abx if epidural abscess
40
Main difference in sx of cauda equina/conus medullary lesions and higher up lesions
Leg weakness is flaccid and areflexic instead of spastic and hyperreflexic
41
Clinical features of conus medullary lesions
Mixed UMN/LMN leg weakness
Early urinary retention and constipation
Back pain and sacral sensory disturbance
Erectile dysfunction
42
Clinical features of cauda equina
Back pain and radicular pain down legs
Asymmetrical, atrophic, areflexic paralysis of legs
Sensory loss in root distribution
Reduced sphincter tone
43
Sensation of dorsal column damage
Hypersensitive or vibratory feelings
44
Causes of unilateral foot drop - 5
```
Diabetes
Common peroneal nerve palsy
Stroke
Prolapsed disc
MS
```
45
Causes of weak legs with no sensory loss - 2
MND
| Poliomyelitis
46
Causes of chronic flaccid paraparesis - 2
Peripheral neuropathy
| Myopathy
47
Causes of spastic paraparesis - 5
```
MS
Intrinsic cord tumours
Cord mets
MND
Syringomyelia
```
48
Causes of absent knee jerks and extensor planters - 5
```
Cervical and lumbar disc disease
Conus medullaris lesions
MND
Friedreich’s ataxia
Subacute combined degeneration of cord - vit B12 deficiency
```
49
Spastic gait appearance
Stiff, circumduction of legs
| Scuffing of foot
50
Extrapyramidal gait disorder
Flexed posture, shuffling feet, slow to start, postural instability
Parkinson’s
51
Apraxia gait disorder
Feet glued to floor or wide based unsteady gait with tendency to fall
Caused by normal pressure hydrocephalus or multi-infarcts
52
Ataxic gait
Wide based, falls, cannot walk heel to toe
Caused by
- cerebellar lesions (MS, alcohol)
- proprioceptive sensory loss (sensory neuropathy, B12 def)
Worse in dark or eyes closed
53
Myopathic gait abnormality
Waddle - hip girdle weakness
| Cannot climb stairs or sit from standing
54
Psychogenic gait abnormalities
Bizarre, not conforming to pattern
| Can’t stand despite no signs when examined
55
Tests for gait disorders
```
Spinal X-ray, MRI
FBC, ESR, syphilis serology, B12, UE, LFT
PSA, serum electrophoresis
CXR
LP
EMG, muscle +- sural nerve biopsy
```
56
Examples of symptoms movement disorders
```
Ataxia
Dystonia, dyskinesia
Gait problems
Parkinsonism
Chorea
Myoclonus
Spasticity
Tics and tremor
```
57
3 things to note on tremor
Frequency
Amplitude
Exacerbating factors eg stresss, fatigue
58
4 types of tremor
Rest - abolished on voluntary movements, caused by Parkinsonism
Intention tremor - irregular, large amplitude, worse at end of purposeful act eg finger-pointing, caused by cerebellar damage (MS, stroke)
Postural tremor - absent at rest, present on maintained posture eg arms outstretched , may persist but not worse on movement, caused by benign essential tremor, thyrotoxicosis, anxiety, B agonist
Re-emergent tremor - postural, developing after delay of 10s (Parkinson’s). Can be helped by surgery or deep brain stimulation
59
What is chorea and 7 causes
Non-rhythmic jerky purposeless movements eg facial grimacing, raising shoulders
Caused by basal ganglia lesion (Huntingdon’s, stroke), strep, SLE, wilson’s, neonatal kernicterus, drugs (L-dopa)
60
What is the chorea which causes significant large amplitude proximal muscle movements
Hemiballismus, contralateral to vascular lesion on subthalamic nucleus
Unilateral proximal joint
Recover spontaneously in a few months
61
What is common in cerebral palsy and often confused with chorea
Athetosis - slow, sinuous, confident, purposeless writhing movements - also known as dystonia.
Caused by lesion in putamen
62
What are tics?
Brief, repeated, stereotyped movements, most common in children and usually resolve
Tourette’s = motor and vocal
Manage = psych support, clonazepam, clonidine if severe
63
What are sudden involuntary focal/general jerks, and its 2 main types
Myoclonus, from cord, brain stem or cerebral cortex
In metabolic problems, neurodegenerative disease, CJD
Benign essential myoclonus - childhood onset, may respond to valproate or clonazepam
Asterixis/metabolic flap - jerking 1-2/s of outstretched hands with wrists extended, from loss of extensor tone - caused by liver/kidney failure, gabapentin
64
What is the complication of antipsychotics long term
Tardivesyndromes - chronic exposure to dopamine antagonists (antipsychotics and antiemetics)
Can be permanent
Can be dyskinesia (choreiform), dystonia (twisting spasms), akathisia (inner restlessness), myoclonus, tourettism or tremor
65
What antipsychotics are less likely to cause tardive dyskinesia?
Quetiapine, olanzapine, clozapine - atypical antipsychotics
66
Cause of acute dystonia, presentation and treatment
From starting drugs eg neuroleptic and antiemetics (metoclopramide, cyclizine)
Torticolis, trismus (oromandibular spasm), oculogyric crisis
Sx disappear with anticholinergic procyclidine IM
67
Risk factors for drug induced acute dystonia
Male
Young
Previous acute dystonia
Recent cocaine use
68
Which tracts transmit which sensations in the spinal cord?
Anterolateral/spinothalamic - pain and temperature
| Dorsal columns - joint position and vibration sense
69
What results from hemicord lesions?
Brown-Sequard syndrome - dorsal column (proprioception and vibration) loss on side of lesion and contralateral spinothalamic (pain and temperature) loss
70
What is dissociated sensory loss?
Cervical cord lesion causes loss of pain ad temperature with sparing of proprioception and vibration
Caused by syringomyelia or cord tumour
71
Sensory loss in cortical lesions?
Confined to discriminating sensory functions eg 2 point discrimination
72
Where can an UMN lesion be?
```
Motor nerve cells in precentral gyrus of frontal cortex
Internal capsule
Brain stem
Cord
Anterior horn cells in cord
```
73
Pattern of weakness/spasticity with UMN lesion
Stronger muscles become spastic - arm flexors and leg extensors, with weakness in opposing muscles
Loss of skilled fine finger movements
74
Findings on exam for UMN lesion
Spasticity is velocity dependent so can suddenly be overcome, eg clasp-knife
Hyperreflexia
Positive babinski (upgoing plantars)
Clonus
75
Where is damage that causes LMN lesions?
Anterior horn cells in cord
Nerve root
Plexus
Peripheral nerves
76
Features of LMN lesion
Wasting, fasciculation
Hypotonia, flaccidity
Reduced reflexes
Flexor plantars
77
Differentiate between LMN and primary muscle disease eg myasthenia gravis
Muscle disease - symmetrical, reflexes lost later, no sensory loss
Myasthenia gravis = fatiguability, little wasting, normal reflexes, no sensory loss
78
Muscle weakness grading
```
MRC classification:
Grade 0 = no muscle contraction
1 = flicker
2 = some active movement
3 = active movement against gravity
4 = active movement against resistance
5 = normal power
```
79
3 impairments causing difficulty speakign
Dysphasia - impairment of language
Dysarthria - difficulty articulating due to incoordination or weakness of musculature for speech, language is normal
Dysphonia - difficultly with speech volume due to weakness of resp muscles or vocal cords
80
Dysphasia associated with difficulty saying words, location of lesion
Broca’s/expressive - non-fluent, malformed words. Reading and writing impairment but comprehension relatively intact. understand question, attempts to convey meaningful answer
Lesion = inferolateral dominant frontal lobe
81
Dysphasia associated with meaningless speech and location of lesion
Wernicke’s/receptive - empty fluent speech with neologisms, oblivious of errors, inappropriate speech
Reading, writing, comprehension all impaired
Lesion = posterior superior dominant temporal lobe
82
2 types of aphasia which are not expressive or receptive
Conduction - interrupted communication between Broca’s and Wernicke’s. Impaired repetition, some comprehension and fluency
Nominal - all fine except naming objects, Posterior dominant temperoparietal lesions
83
What to assess in assessment for dysphasia - 4
1. Comprehension - follow 1/2/3 step commands
2. Repetition
3. Naming
4. Reading and writing
84
Assessing dysarthria and 4 causes and their features
Diffficuty with articulation due to incoordination/weakness of musculature of speech. Repeat phrase eg British constitution
1. Cerebellar disease - slurring and irregular volume, scanning speech
2. Extrapyramidal diseases - soft, indistinct, monotonous speech
3. Pseudobulbar palsy - spastic dysarthria (UMN), slow, nasal and effortful, from MND or severe MS
4. Bulbar palsy - LMN eg facial nerve palsy or guillain-barre - palatal paralysis gives nasal speech
85
Identifying dysphonia and what causes it?
Weakness of resp muscles/cords, precipitated in myasthenia by counting to 100
Dysarthria and dysphonia in Parkinson’s
86
What is dyspraxia and 4 types
Poor performance of complex movements despite ability to do each component, eg mime object’s use
Dressing - unsure of orientation of clothes on body. Nondominant hemisphere lesions
Constructional - difficulty drawing 5 point star - nondominant hemisphere lesions or hepatic encephalopathy
Gait - bilateral frontal lesions, posterior temporal region or hydrocephalus
87
Treat chorea
Dopamine antagonist tetrabenazine
88
Cerebellar signs
DANISH
Dysdiadochokinesia and fingerto nose tests
Ataxia - broad based gait, fall to side of lesion
Nystagmus
Intention tremor
Slurred/staccato speech
Hypotonia andreduced power
89
Test for ataxia
Romberg test - stand with eyes closed
- pos (loses balance) = posterior column disease
- neg = cerebellar disease
90
Findings on exam for complete optic nerve lesion
Ipsilateral blindness and no direct pupillary reflex
| Indirect pupillary reflex intact
91
Findings on exam for optic chiasm lesion
Bitemporal hemianopia as fibres from nasal halves both retinas will be involved
Normal direct, consensual light reflex and accommodation reflex
92
Findings on exam for optic tract lesion
Homonymous hemianopia: right side optic tract lesion = right nasal. And left temporal hemianopias
Normal direct, consensual light and accommodation reflexes
93
Optic radiation lesion findings
Homonymous hemianopia, or inferior quadrantinopia if more posterior to cortex
94
Visual cortex lesion
Homonymous hemianopia
Pupils react normally to reflex stimuli
Macula often spared due to posterior/middle cerebral artery anastamosis
95
Scotoma found with glaucoma
Arcuate scotoma
96
Unilateral horizontal hemianopia cause - 3
Arterial occlusion, retinal vein thrombosis, inferior retinal detachment
97
Cause of central scotoma - 2
Macular degeneration or macular oedema
98
Test for macular disease - 2
Central scotoma
| Amsler grid for distortion in central vision
99
Pituitary tumour findings and why
Disrupts chiasm so bitemporal field defects, can superimpose central optic nerve. Defect icon onesidemore
100
Process from optic nerve to brain
```
Optic chiasm
Optic tract
Lateral geniculate body
Optic radiations
Visual cortex
```
101
Temporal lobe tumour visual defect
Contralateral upper homonymous quadrantinopia
102
Causes of visual cortex field defects
```
Ischaemia - TIA, migraine, stroke
AVM
Glioma, meningioma
Abscess
Drugs - ciclosporin
```
103
What is dementia
Progressive global decline in cognitive function
104
2 types of dementia and causes of each
Degenerative - AD, PD, multi-infarct, Lewy body, Huntingdon’s, Wilson’s
Reversible - brain (SDH, NPH), drugs, infections (HIV, neurosyphilis), metabolic (low T4, low B12, high calcium) [DIM]
105
Inv for dementia?
Confusion screen:
Collateral history, MMSE
Bloods - FBC, UE, LFT, TFT, haematinic (ferritin, B12), bone screen (calcium), glucose
Other fluids - urine mcs
X-ray - cxr, CT head (small vessel disease = variant on multi infarct dementia)
[BOX]
106
Manage areas in dementia
Social - Activity, Adl help (mobility, nutrition, continence), Anticipatory planning
Psycho - Ask about depression
Bio - Address reversible, Ad drugs (acetylcholinesterase inhibitor, NMDA antagonist)
[6As]
107
Adv and disadvantages of MMSE
Adv - quick and easy, monitor changes
| Dis - bias against blind or uneducated, poor sens for mild dementia
108
Marks for MMSE
20-24 = mild
12-20 = moderate
<12 - severe
109
Drugs for dementia
ACh inhibit for - donezepil, galantamine, rivastigmine for mild/mod
+ or swap for memantine - glutamate receptor antag when severe
110
NPH features
Triad:
Dementia
Gait disturbance ‘magnetic’
Urine incontineince
111
NPH inv
Dilated ventricles, no RICP on CT
112
Manage NPH
VP shunt helps if CSF removal post-LP improves sx
113
Features of Lewy body
Fluctuating memory loss
Visual hallucinations - kids animals
Parkinsonism features - eventually
114
Pathology of Lewy body
A synuclein inclusions bodies
| >65yo
115
Causes of delirium
Brain - bleed (EDH, SDH, SAH), infection (meningitis, encephalitis), stroke, tumour
[DIM] - others - drugs (opiates, benzo and withdrawals), infection, metabolic (hypovolaemia, hypoxia, electrolyte, anaemia)
116
What is delirium
Acute confusional state characterised by fluctuating cognitive impairment
117
Types of delirium and features of each
Most common - hypoactive - decreased arousal, apathy
Hyperactive - increased arousal, agitation
Both - altered sleep, wake; hallucinations
118
Manage delirium
Confusion screen - treat cause
Optimise factors - light, glasses, hydration, nutrition, bowels, pain
Sedatives if last resort and disruptive - haloperidol
119
Assessing delirium - 2
```
AMT:
Time
Year
Current place
Address
DOB
Time
Age
2 people
Monarch
WW1 end date
Count back 20-1
```
Or Confusion Assessment Method
120
Feature of SDH and cause
Fluctuating confusion for a while
| Rupture off weak bridging vessels between cortex and venous sinuses leading to haemorrhage between dura and arachnoid
121
CT blood on SDH
Black - chronic blood
122
COPD with uncontrolled oxygen and confusion - what investigation
ABG = T2 respiratory failure
123
What is a fall
Unintentional loss of blance resulting in coming to rest below knee level
124
Causes of non-syncope fall
```
Mobility
Balance
Visual
Cognitive
Hazards - wet floor
```
125
Syncope causes of fall
Cardiogenic - arrhythmia, HOCP (ask about sudden cardiac death), AS, MI, PE
Neurogenic - seizure, CVA, hydrocephalus
Vasogenic - vasovagal, carotid sinus/micturition
126
Causes of fall - syncope or nonsyncope
```
Hypoglycaemia
Postural drop
Drugs
Infection
Metabolic
```
127
Post-falls assesment key questions
1) why did they fall, 2) did it cause an injury
History
Exam
Investigations
128
Hx in post falls assessment
Hx -
before (trigger, warning sx),
during (timing, consciousness, incontinence, tongue biting),
after (recovery time, postictal)
129
Exam post falls
Obs - lying/standing BP, BM
Drug chart - anticoagulants (brain bleed), psychotropic, htn
Full CVS, neuro incl CN, injury sites - head, c spine, hips, knees
130
Inv in post fall assessmsent
ECG, 24h tape
| Imaging - CT head, X-ray neck, X-ray pelvis
131
Aims of falls risk assessment
Prevent future fall
| Protective measures if do fall
132
Who is at risk of falling
Age >65yo
>1 fall in last year
RF - mobility, visual, balance, cognitive and refer on
133
Manage fall risk in clinic - 5
```
RF
Home hazards
Timed up and o test, turn 180 degrees
Medication review - anticoagulation etc
Osteoporosis risk
```
134
Bone assessment in elderly - 3
FRAX - 10y risk of fracture
DEXA
Bisphosphonates
135
DEXA scan results
T score:
-1 - -2.5 = osteopoenia
< -2.5 = ostoporosis
136
Manage low DEXA score
1st line - alendonate
2 - other PO Bisphosphonates
3 - newer agents, zoledronate IV
137
CT head immediate criteria - 4
GCS <13 at assessment of <15 2h after
Suspected basal skull, open or dep[ressed fracture
Seizures or focal neuro
vomiting >1
138
CT head urgent criteria - 4
Retrograde amnesia >30m
High impact trauma
Bleeding diathesis - warfarin, clotting disorder
Age >65yo
139
Hx of weakness?
[STEERS]
Start point - morning? (Stroke)
Timings - come and go, getting better/worse
Explain it - where (asymmetrical) and effects on life
Exacerbating
Relieving factors
Sx screen:
- Sensory
- Functions - speech, swallow, sphincter
- Fits, faints, funny turns
- meningism - headache, vomiting, neck stiff, photophobia
140
Focal weakness causes - 5 areas
```
UMN only -
Stroke
MS
Tumour
Bleed
Meningitis
```
UMN and LMN (mostly cord) -
MND
Cord disease
LMN only - neuropathy
NMJ - MG
Muscle - myopathy
141
Generalised causes of weakness
```
Frailty
Anaemia
Sarcopoenia
Hypoglycaemia
Electrolytes
Hypoxia
Infection
Drug related
```
142
Ischaemic stroke - 3 types and exam findings
Emboli - cardiac, carotid
Thrombotic in situ - large vessel, small perforated
Rare - [3Vs] vasospasm for SAH, Vasculitis, Vvatershed stroke
AF, murmur, carotid bruit
143
Haemorrhagic stroke - 6 causes and exam findings
[HHAATT]
Head injury and Htn
Anticoagulation and AVN
Thrombolysis and Tumour
Meningism, seizures, LOC
144
Stroke mimics - 4
Hypoglycaemia, Hemiplegic migraine
Todd’s palsy (frontal lobe epilepsy), Tumour/haemrrange
[HHTT]
145
Cardiac emboli strokes
TACS and PACS
146
Small vessel thrombotic diseae
| Large vessel thrombotic disease
LACS
| POCS
147
Why is macular spared in POCS
Bilateral supply
148
MCA stroke features
[Ms]
Mouth and arms
Mechanical speech impairment - broca’s
149
ACA stroke features
Legs and Wernicke’s
150
Cerebellar stroke
DANISH
151
Brainstem stroke features
Same side = CN problems
| Other side = peripheral nerve problems
152
Wallenberg - PICA
IL Horner, dysphagia, DANISH
| CL sensory
153
Weber - PCA midbrain
IL CN3
| CL weakness
154
Pontine stroke
IL CN6/7
| CL weakness
155
Types of brainstem stroke
PICA, MCA midbrain, pontine
156
Manage stroke immediate
```
[ACT]
Aspirin 300mg 2w then clopidogrel 75mg
Consider thrombolysis (<4.5h, contraindications, <80yo) and neuro referral if cerebellar (coning) or malignant MCA (oedema on infarct)
Transfer to stroke unit - monitor BP and BM (enough supply to penumbra by keeping BP in range)
```
157
VTE after stroke?
Dont’ start LMWH as increased risk of haemorrhagic stroke
| Aspirin 300mg
158
LT stroke management
Cannot drive for 1m, tell DVLA if permissive neuro defecit
Statin >2d, warfarin >2w ifAF, stop clopidogrel
CEA <2w if symptomatic stenosis
PT/OT/dietician
NBM then SALT
159
TIA assessment?
```
ABCD2 criteria
Age
BP
Clinical features
Duration of sx
Diabetes
```
<4 - clinic <1
>=4 clinic in 24h
160
Manage TIA
Aspirin 300mg, statin, ECG
TIA clinic within 24h
ABCD2 assessment
161
MS ?
AI CNS demyelination - discrete plaques disseminated in time and space
162
Types of MS
Relapsing remitting
| Secondary or primary progressive
163
MS ?
AI CNS demyelination - discrete plaques disseminated in time (different times) and space (different probems)
T cell demyelination repairs slowly
164
Types of MS
Relapsing remitting
| Secondary or primary progressive
165
Features of MS
Visual - optic neuritis (most common presentation), bilateral INO, uhthoff phenomenon (worse in heat)
Sensory - limb tingling, Lhermitte’s sign
Motor - spastic paralysis (UMN), bowel/bladder dysfunction
Cerebellar - dAnish (A most common in relapsing)
166
inv MS
MRI brain and spinal cord
T2 [2 letters in MS] with gadloneum contrast
LP - oligoclonal bands, ensure no inf before starting steroids
167
Manage MS
Relapse - steroids IV 3d (ensure no inf first) then PO
| Remission - DMARDs eg interferons (if >2 relapse in 2y), biologics, symptomatic (spasticity, pain, urinary retention)
168
Open angle glaucoma fundoscopy
Optic disc cupping
169
Complication when DMARD started for MS
Misdiagnosis - Neuromuscular optica = optic neuritis and transverse myelitis
Check anti-NMO antibodies when diagnosing MS
Gets worse with DMARDs
170
Manage spasticity in MS
1 - Baclofen
| 2 - Botulinum
171
Which ascending tract crosses
Lateral spinothalamic
172
MND?
Degeneration of upper motor neurones,
CN and anterior horn nuclei - LMNs
Loss of corticospinal, corticobulbar tracts and anterior horn cells
Generally UMN signs in legs and LMN in arms
173
Most common MND
Asymmetrical lateral sclerosis in anterior horn
174
Features of asymmetrical lateral sclerosis
LMN arms - thenar wasting, split thumb, fasciculations
| Umn legs
175
4 types of MND
Asymmetric lateral sclerosis
Primary lateral sclerosis
Progressive muscular atrophy
Progressive bulbar palsy
176
Diagnosis of MND
Exclusion
| Motor only, mixed umn/lmn or fasciculatins - suspect
177
Manage MND
MDT
Riluzole - anti glutaminergic
Symptomatic/supportive
Baclofen, diazepam
178
Causes of cord ccompression - 5
```
Trauma - post disc prolapse
Tumour - myeloma, mets
Bleeding - haematoma
Infection - abscess
Degeneration - spondylosis
```
179
Red flags for cord compression
[4Bs]
Back pain
Bilateral neurology incl saddle anaesthesia
Bowel/bladder accident
B symptoms - fever, night sweats, weight loss
180
Bottom of cord?
Conus medularis L1 - S5
181
Intrinsic cord disease? - 5
Tracts:
Vascular - ASA infarction = anterior lateral tracts
Inflammation - MS
Infection - HTLV1
Metabolic - SACCD in b12 def
Congenital - syringomyelia, Friedrich ataxia
182
Immediate management of malignant cord compression
Dexamethasone
MRI
Neurosurgery referral
183
What are polyneuropathyies
symmetrical and distal - demyelination gets or axonal
184
Motor polyneuropathy
LMN features
Guillan barre, paraneoplastic
185
sensory neuropathy eg feature and causes
Glove and stocking
DM, alcohol, b12
186
Mixed neuropathy features and causes
Postural drops
Retention/constipation
Point and Shoot
Diabetes, Guillan barre, HIV
187
Myasthenia gravis?
AI - anti achr, anti musk
188
Motor polyneuropathy features and causes
LMN features
Guillan barre, paraneoplastic
189
Sensory polyneuropathy feature and causes
Glove and stocking
DM, alcohol, b12
190
Manage MG
Anticholinesterase - pyridostigmine
Immunosuppression - rescue IVIG, plasma X; DMARDs
Thymectomy
191
Myopathy?
Symmetrical proximal muscle wasting/weakness
| Inherited or acquired
192
Inv myopathy
Raised CK
EMG shows short action potential
Muscles biopsy diagnostic
193
Inherited myopathies - 3
Musclular destroy
Myotonic dystrophy
Mitochndrial
194
Acquired myopathies - 3
Myositis
Metabolic
Medicatios
195
Assessing resp muscle weakness in neuromuscular disorder
FVC <1.5l
= ABG - T2RF
== ITU
196
Cause of guillan barre and process
Campylobacter jejuni produces antibodies that cross reacts
| 2w before weakness starts
197
Inherited of DMD
X linked recessive
198
Causes of incontinence
Stress:
[Ps]
Pelvic floor weakness
Urge:
[Ds]
Detrusor overactivity
199
Manage incontinence
Stress -
Pelvic floor exercises
PV tension free tape
Urge -
Diary and retraining therapy
Drugs - anti muscarinics
200
Retention of urine causes
Inpatient - 4Cs - constipation, Catheter blocked, colonised (inf), chemicals
Outpatient - prostate, pelvic mass, paralysed bladder
201
Presentation of urine retentiona n
No uterine
Distended palpable bladder
Delirium
202
Inv urine retention
Bladder scan.- >500lm residual
US KUB for hydronephrosis
UE AKI
203
Treat retention of urine
Identify cause and reverse
Catheterise - clot washout, tamsulosin, gentamycin
Chronic - catheterise with long term and refer
204
Key drugs involved in cyp DDIs
```
Statin
Warfarin
OCP
Theophylline
[SWOT]
```
205
Red flag sx headache
Meningitic - neck stiff, photophobia, fever, vomiting rash
Pressure - worse on strain or morning, vision
GCA in elderly - jaw claudication, scap tenderness (brushing hair)
206
Red flag diagnoses
```
Inf - meningitis, encephalitis
Bleed (EDH, SDH, SAH)
Clot (pill?)
SOL
Acute closed angle glaucoma
GCA
```
207
Chronic headaches - 3 causes
Tension headache
Migraine
Cluster headache
208
Migraine diagnosis
```
5 attacks
Lasting 4 hours to 3 days
2 of unilateral, pulsating, severe affecting life
1 of NV, phonophobia, photophobia
[54321]
```
209
Aura type in migraine?
Visual
| Motor
210
Common triggers for migraine
Crap time - stress
Certain food - cheese, chocolate, caffeine
COCP
211
Treat mild headache with hx of asthma?
Paracetamol
| No naproxen as asthma
212
Severe occipital headache with hx of aut dom polycystic kidney disease
SAH - CT head or LP after 12h if neg CT
213
Why wait for 12h to do LP for SAH
Wait for blood to breakdown to bilirubin - xanthochromia, as can get blood on LP anyway from trauma
214
Treat idiopathic intracranial htn - 4
Weight loss
Acetazolamide
Topiramate - prevent seizures
VP shunt/ON fenestration
215
Sx of IIH - 4
Bilateral blurred vision with blurred discs on fundoscopy
| Long term headache, worse with sex
216
Unilateral headache
Pale optic disc
Amaurosis fugax
GCA - steroids and hospital
| = Anterior ischaemic optic neuropathy
217
GCA fundoscopy findings
Pale optic disc - anterior ischaemic optic neuropathy
218
2 causes of pale optic disc
Anterior ischemic optic neuropathy - arteritic or nonarteritic (clot)
GCA
219
Classify seizure
Epilepsy vs provoked
Partial.- simple, complex
Generalised - tonic clonic, absence
220
Inv epiepsy
EEG, MRI brain
221
seizure treatment
First fit clinic
Driving - no drivin 6m after 1st seizure, 1y seizure free to restart
AED - cbz for partial (not in absence), valproate for generalised, lamotrigine/levitiricitam
222
Temporal epilepsy sx - 4
Hallucinations
Epigastric rising
Automatisms
Deja vu, dysphasia post ictal
223
Frontal epilepsy sx - 3
Motor - posturing, head movements
Jacksonian march
Weakness post ictal - Todd’s
224
Parietal epilepsy sx
Sensory
225
Occipital epilepsy sx
Visual
226
AED in pregnancy
Lamotrigine
227
Manage status epilepticus
```
A-E, recovery position
After 5m - IV lorazepam 2-4mg,
After 15m - repeat bolus
After 20m - phenytoin, anaesthetist
After 30m - RSI, intubate, ITU
```
228
Status epilepticus OSCE activities - 2
1) Start timing
| 2) Start drawing up lorazepam 2-4mg 2x boluses, and phenytoin
229
Pseudoseizures - 3
Unexplained movements
Rapid resolution
Triggers eg stress
230
Rapidly resolving unpredictable seizures?
Pseudoseizure
231
Types of tremor
[RAPID]
Resting - sow, asymmetrical, pill rolling, relieved by movement and worse with distraction
- PArkinson’s
Action/postural - rapid, symm, both arms, worse with outstretched arms, relieved at rest
- BEATS
Intention - rapid, large amplitude, irregular, worse with finger pointing end, better with rest
- cerebellar causes
Dystonic - variable
232
Causes of action or postural tremor
```
Benign essential tremor
Endocrine - hyperthyroid
Alcohol withdrawal
Toxins - b agonist
Stress//anxiety
[BEATS}
```
233
Parkinson’s diseae?
Reduced dopamnergic neutrons in pars compacta of substantianigra
234
Sx parkinson’s
```
Motor change - hypokinesia, rigidity, resting tremor - UL onset
Autonic instability
Sleep disorder
Krazy - depression
[MASK]
```
235
Manage Parkinson’s
Levidopa if unwell and carbidopa (prevents peripheral breakdown to improve brain action) - only last <5y
- SE = motor - on/off fluctuations (off when wearing off), dyskinesia
Dopamine agonist if well
- SEs - postural drop, nausea, visual hallucinations, fibrosis if ergo-derived
Prolong on time: MOA-B inhibitor selegiline, COMT inhibitor entacapone
Reduce dyskinesia: NMDA inhibitor
236
When to rule out parkinson’s disease with tremor
Bilateral/symmetrical at start - Parkinsonism
237
Manage benign essential tremor
Propanolol
238
Features of benign essential tremor
Aut dom
Better with alcohol
Worse with specific movements
239
What is Bell’s palsy 2 RF and inv and management
```
CN7 palsy, diagnosis of exclusion
Unilateral weakness including forehead
Decreased taste
Numbness or pain around ear
Abrupt onset
RF pregnancy, diabetes
```
ESR
MRI for SOL, MS or stroke
Can do nerve conduction study after 2w predicts prognosis - slow if axonal degeneration
Incomplete recovers in a few weeks, complete paralysis mostly will make full recovery
Prednisolone in first 72h, protect eye with tape
240
Types of delirium and key features
Acute confusional state, hyperactive, hypoactive or mixed
Primary = personality abnormalities, found after crisis eg loss of spouse
Assess with AMTS, MoCA, MMSE
1. Cognitive impairment
2. Rapid onset - days to weeks
3. Fluctuating severity - worse at night
241
Predisposing factors for delirium
```
Dementia
Old
Polypharmacy
Functional or sensory impairment
Malnutrition
Comorbidities
```
242
Precipitating factors for delirium
```
Hospitalisation
Catheterisation
Acute illness
Electrolyte disturbances - sodium
Drugs - opiates, anticholinergics, sedation
Renal impairment
Alcohol
Peri-op
Constipation
```
243
Differentiate delirium from dementia
Delirium - sudden onset, reversible, impaired consciousness, inattentive, psychomotor changes
Dementia - insidious, permanent, no impairment of consciousness, normal attention, no psychomotor changes
244
What is dementia and diagnosis
Progressive impairment of higher cortical functions, including memory, language, emotional control and social behaviour
Must affect ADLs
Clinical cognitive assesments eg AMT, MMSE, MoCA - attention, memory, language, execute, apraxia, visuospatial
Focal neurology, FBC including calcium, BM, B12, folate, TFT
ECG, EEG, CXR, MSU
CT/MRI
245
Alzheimer’s, what is it, 4 RF for dementia and management
Amyloid deposits - progressive degeneration of cortex - global impairment
Female
Family hx
Caucasian
Apolipoprotein E
Treat - supportive
Mild - AChEi galantamine or donepezil
Mod - NMDA antagonist memantine
246
Vascular dementia
Macroscopic - single insult, or microscopic - number of microemboli
RF - male, CVD, smoker, obestiy,, DM, htn
Acute or subacute, focal or functional sx eg mood change
Treat contributing factors
247
Lewy body dementia
A synuclein deposits in brainstem and neocortex
Multitasking lost first, then memory. Fluctuating cognitive impairment, hallucinations, sleep disorder
Treat - ?rivastigmine
Avoid PD drugs, antipsychotics and sedatives
248
Differentials for dementia
```
Alzheimer’s
Vascular
Lewy body
Frontotemporal - Pick’s
Normal pressure hydrocephalus
Depression
```
Mild cognitive impairment - objective cognitive impairment but doesn’t meet dementia criteria
249
Features of extradural haemorrhage
Lucid interval then deterioration consciousness, headache, confusion, fits
Hemiparesis, brisk reflexes, upwards plantar
Eventually, ipsilateral pupil dilates
250
What is Horner’s syndrome and causes
1. miosis
2. Partial ptosis
3. Anhydrosis
From interruption to sympathetic supply - thoracic outlet (pancoast), brainstem (demyelination or vascular) or cord (syringomyelia)
251
ABx for meningitis in adults
Cefotaxime and ampicillin if >55yo
| Cefotaxime alone if <55yo
252
Triptans and CI to triptans
5-HT3 agonist
Coronary artery spasm
Uncontrolled ypertension
SSRIs
253
Prevention of migraine
If >=2 a month or not responding to treatment
1 - Propranolol, amitryptiline, calcium channel blockers
2 - Valproate, gabapentin,
254
What is MND and sx
Selective loss of UMN in cortex, cranial nuclei and anterior horn cells
- UMN, LMN and bulbar signs
Sx - stumbling spastic gait, foot drop, prox myopathy
Doesn’t affect eyes or sphincters
Treat: sx eg baclofen for spasms, analgesia
Anti-NMDA drugs
255
Grading of SAH and management and 4 complicatiotns
```
1 - no sx
2 - neck stiffness and CN palsy
3 - drowsy
4 - drowsy with hemiplegia
5 - coma
```
Immediate surgery and endovascular coiling, measure GCS, pupils and BP and repeat CT if deteriorate
Nimodipine - calcium ch antagonist reduces vasospasm and morbidity from cerebral ischaemia
Rebleeding
Cerebral ischaemia from vasospasm
Hyponatraemia
Hydrocephalus from blocking arachnoid granulations
256
What drugs to start for temporal arteritis
Prednisolone
PPI
Alendronate
257
Wernicke’s encephalopathy features
Confusion
Ataxia
Opthalmoplegia
Memory loss, hypothermia, hypotension, reduced consciousness
From thiamine B1 deficiency
Treat with thiamine IV then PO
258
Requirements for diagnosis of different strokes
1. Unilateral weakness
2. Homonymous hemianopia
3. Higher cerebral dysfunction
```
TACS = 3
PACS = 2
```
POCS: 1 of:
1. Cerebellar dysfunction
2. LOC
3. homonymous hemianopia
LACS: 1 of:
1. Unilateral weakness +- sensory of face, arm or leg
2. Pure sensory
3. Ataxic hemiparesis
259
Manage TIA
```
Aspirin 300mg and statin
ABCD2 score -age (60yo), bp (140), clinical features (1-2), duration (1 = <1h or 2), diabetic
1-2 = clinic in 7d
3 = clinic in 24h
4+ = admit
```
260
What is Huntingdon’s disease
Aut dom chronic progressive chorea and marked mental deterioration, present 30-50yo
Cerebral atrophy with loss of neutrons in putamen and caudate nucleus
Personality, mood and cognition change
Chorea, walking, speech - eventual akinesia and rigidity
Dementia
Early depression and increased suicide risk
Death in 10-20y of onset
Manage:
Antipsychotics
Tetrabenazine suppresses chorea
Antidepressants
261
Cellulitis classification
Eron classification:
1 - no systemic sx
2 - systemically unwell or has comorb that may delay resolution
3 - significant systemic illness or comorbidity that may interfere with treatment or lead to vascular compromise and limb threatening infection
4 - sepsis or life threatening infection
Admit if: 3-4, severe or deteriorating, immunocompromised of facial
Stage 1 - oral flucloxacillin 7d
262
Signs of degenerative cervical myelopathy and treatment
Neck pain
Bilateral median nerve dysfunction
Sensory, motor, autonomic
MRI - cervical canal stenosis
Manage: surgical decompression, physio and analgesia
263
Chronic inflammatory demyelinating polyneuropathy
Widespread neuropathy, motor symptoms predominant
MRI to rule out MS
CSF = high protein
Treat - high dose steroids
264
Subacute degeneration of cord
B12 deficiency
Posterior column first = proprioception, light touch, vibration
Lateral = spastic weakness, UMN signs
265
Brown sequard
Contralateral pain, temperature and crude touch
| Ipsilateral UMN, vibration, proprioception and fine touch
266
Cause of CN3 palsy and sx
Posterior communicating artery aneurysm - severe headache and loss of visual acuity
down and out, ptosis, dilated
267
Encephalitis causes and inv and treatmetn
Virus - HSV1/2, EBV, CMV, measles
Bacteria, Tb, malaria
```
Inv - bloods, cultures, PCR
Throat and urine swabs
CT
LP
EEG
```
Empirical acyclovir for HSV
Then treat identified cause and supportive
268
Sx and inv and management of cerebral abscess
Sx - fever, seizures, localising sign, RICP, coma, sign of sepsis eg ear, tooth, lungs
Inv - WCC and ESR high, CT/MRI
Manage - neurosurgery, treat RICP
