Neurology Flashcards
1
Q
Difference between UMN and LMN lesion
A
- UMN: Spastic, brisk reflexes ++, regional distribution, upgoing plantars
- LMN: Atrophy ++, fasiculations, flaccid, diminished reflexes, segmental distribution, downgoing plantars
2
Q
Common meningitis orrganisms by age
A
- Neonates- GBS, E. coli
- Infants- HiB
- Adults + older children- N. Meningitidis, S. pneumoniae
- Elderly/ immunocompromised- CMV, listeria
- Viruses eg HSV, HIV
- Fungi eg Candida (immunocomp)
3
Q
Presentation of Meningitis/ meningococcal septicaemia
A
- Headache ++
- Neck stiffness
- Photophobia
- Confusion, low GCS, seizures, coma, +/- focal signs
- Vomiting
- Myalgia, arthralgia
- Fever
- Shock- Tachycardia, hypotension, cool peripheries
- Non-blanching rash- septicaemia
- Brudinski’s
- Kernig’s
4
Q
What is Brudinski’s sign and what does it indicate?
A
- Passive neck flexion when legs flexed
- Meningitis
5
Q
What is Kernig’s sign and what does it indicate?
A
- Hip flexed to 90 degrees –> unable to straighten leg.
- Meningitis
6
Q
Ix and Tx of meningitis
A
- Ix:
- Bedside- throat/rectal swabs, fundoscopy
- Bloods- FBC, U+Es, LFTs, CRP, culture, glucose, coags
- Imaging- CXR (?TB), CT head ?raised ICP
- Special- LP
- Tx:
- GP- IM Benzylpenicillin
- ABCDE + IVT
- Dexamethasone –> CT/LP
- Cefotaxime 2mg slow IV (+ampicillin if >55y). Before LP if delayed.
- Shock –> ICU –> ?intubation ?inotropes
- Ongoing Tx- D/w micro. ?viral –> aciclovir. Contact prophylaxis with ciprofloxacin/ rifapmicin. Contact public health.
7
Q
Interpretation of LP results
A
- Bacterial- Yellow/ turbid. +++ WCC/granulocytes, +++ protein, low protein
- Viral- Clear. ++ lymphocytes
- TB- Yellow/ viscous. +++ lymphocytes. Low protein.
8
Q
Causes and presentation of encephalitis
A
- Causes:
- Mainly viral (HSV, CMV, EBV, VZV, mumps, Japanese encephalitis).
- Others- any bacterial meningitiis, TB, malaria, Lymes etc
- Presentation:
- Infectious prodrome
- Odd behaviour
- Headache
- Confusion/ Low GCS/ coma
- Seizures
- Focal neurology
- Meningism
9
Q
Investigations and treatment of encephalitis
A
- Ix:
- Bedside- throat + MSU cultures, EEG
- Bloods- Cultures, serum viral PCR
- Imaging- contrast enhanced CT, MRI - temporal lobe changes
- Special- LP (high protein and lymphocytes, low glucose) –> PCR
- Tx:
- Aciclovir within 30 mins for 14 days (HSV protection) –> guided by micro
- HDU/ITU
- Supportive and Symptomatic eg seizures
10
Q
Key features and causes of cerebral abscess
A
- Features- Raised ICP, fever, low GCS/ coma, localising signs.
- Causes- may follow ear/ sinus/ dental infection. Or congenital heart disease/ endocarditis/ bronchiectasis
- Ix- bloods, CT, MRI
- Tx- Neurosurgery
11
Q
Causes of raised ICP
A
- Trauma
- Tumour- primary vs mets
- Infection- meningitis/ encephalitis/ cerebral abscess
- Haemorrhage
- Hydrocephalus
- Cerebral oedema
- Status epilepticus
12
Q
Presentation of raised ICP
A
- Headache- worse leaning forward/ coughing
- Vomiting
- Low GCS/ confusion/ coma
- Seizures
- Cushing’s response- hypertension, bradycardia
- Cheyne-stokes breathing
- Pupil changes
- Poor visual acuity/ peripheral visual fields
13
Q
Investigations and treatment of raised ICP
A
- Ix:
- Fundoscopy, HR, BP, neuro obs
- Bloods- FBC, U+Es, LFTs, glucose, serum osmolality, clotting, culture
- Imaging- CXR (?source), CT head
- Special- LP, ?ICP monitor/ bolt
- Tx: Tx cause
- ABCDE. MAP kept >90mmHg. Tx seizures
- Elevate bed head 30-40 degrees
- If ventilated –> hyperventilate
- Osmotic agents- mannitol
- ?tumour –> dexametasone
- Restrict fluids <1.5L/d
- NEUROSURGERY! Craniotomy/ burr hole
14
Q
What is a subarachnoid haemorrhage and how might it present?
A
- = Bleed between pia and arachnoid mata in subarachnoid space. 80% due to aneurysm.
- Presentation:
- Sudden occipital headache ++
- Vomiting
- Collapse
- Seizures
- Coma/ low GCS/ drowsy
- Focal neurology
- Photophobia
- Neck stiffness
- Kernig’s
15
Q
Ix and Tx of subarachnoid haemorrhage
A
- Ix:
- Urgent CT head (hung chicken)
- >12h –> LP (xanthochromia)
- Tx:
- ABCDE resus
- Cons- lie flat, neuro obs
- Morphine + metoclopramide
- Nimodipine prevents vasospasm
- Beta blocker - SBP <130mmHg
- Surgery- aneurysm coiling, evacuate haematoma, relieve hydrocephalus
16
Q
What is a subdural heamatoma, what causes it and how might it present?
A
- = venous bleed between dura and arachnoid mata
- Causes- trauma, low ICP, dural mets
- Presentation:
- Fluctuating consciousness
- Insidious physical/intellectual slowing
- Sleepines
- Headache
- Raised ICP
- Low GCS
- Seizures
- Chronic- more likely in elderly, alcoholics, patients on anti-coagulation
17
Q
Ix and Tx of subdural haematoma
A
- Ix- CT/MRI= crescent shaped collection of blood over 1 hemisphere +/- midline shift
- Tx- Surgery! Burr hole –> craniotomy
18
Q
What is an extradural bleed and how might it present? + Ix and Tx
A
- = Bleed between bone and dura. Usually temporal trauma –> lacerated middle meningeal artery.
- Presentation:
- Well in lucid period –> declining GCS over 4-8h
- –> Headache, vomiting, confusion, fits, UMN signs
- –> pupil dilation, coma, weakness, irreg breathing, Cushing’s response
- Ix- CT head = lemon. Head x-ray ?fracture
- Tx- Neurosurgery ASAP (evacuation)
19
Q
Signs of basal skull fracture
A
- CSF/ blood leaking from ears/ nose
- Battle’s sign- bruising over mastoid process
- Blood behind ear drum
- Panda eyes
20
Q
Indications for CT head
A
- GCS <13
- GCS <15 with head injury persisting 2 hours after injury
- Focal neuro deficit
- ?depressed skull fracture/ basal skull fracture
- Post-traumatic seizure
- Vomiting > once i
- LOC + 1 of: >65y, coagulopathy, antegrade anesia, high risk injury eg car crash
21
Q
Tx of head injury
A
- ABCDE + check c-spine + o2 + IVT
- ?Intubate
- Seizures –> lorazepam
- Ix- U+Es, glucose, FBC, blood alcohol, toxicology, ABG, clotting.
- Evaluate lacerations
- Palapate neck tenderness ?c-spine injury –> immobility + CT/ X-ray
- Trauma series? CT neck/ chest/ abdo/ pelvis
22
Q
Define a stroke and TIA
A
- Sudden onset of Sx lasting >24h, with focal loss of cerebral function of presumed vascular origin.
- Stroke= >24h
- TIA= <24h
23
Q
Causes of ischaemic and haemorrhagic stroke
A
- Ischaemic:
- Atherosclerosis
- Atherothromboembolism from carotid
- Cardiac embolism- AF, MI, endocarditis
- Arterial dissection
- Haemorrhagic:
- Hypertension
- Trauma
- Aneurysm rupture
- Anticoagulation
- Thrombolysis
24
Q
Features of TACS
A
- All 3 of:
- Hemiparesis/ hemiparalysis in face/ arm/ leg
- Homonymous hemianopia
- Higher cortical function- dysphasia/ inattention
- Cortical MCA/ ACA
25
Features of PACS
* 2 of:
* Hemiparesis/ hemiparalysis in face/ arm/ leg
* Homonymous hemianopia
* Higher cortical function- dysphasia/ inattention
* Cortical MCA/ ACA
26
Features of POCS
* 1 of:
* Cerebellar/ brainstem syndrome (Dysdiadokokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia)
* LOC
* Isolated homonymous hemianopia
27
Features of LACS
* Lacunar/ subcortical small vessel disease
* No evidence of higher cortical dysfunction + 1 of:
* Hemiparesis/ hemiparalysis face/ arm/ leg
* Pure sensory stroke
* Ataxic hemiparesis
28
NIH stroke score
1. Level of consciousness, LOC questions and commands
2. Best gaze
3. Visual fields
4. Facial paresis
5. Motor arm (L+R
6. Mortor leg (L+R)
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction and inattention
29
Stroke RF
* Cardiac RF
* OCP
* \>55y
* HTN
* Hypercholesterolaemia
* DM
* Alcohol
* Drugs
* Obesity
* PMH/ FHx
* Carotid bruit
30
Features of cerebral, brainstem and lacunar infarcts
* Cerebral- Sensory/ motor loss, dysphasia, homonymous hemianopia, visuospatial defect
* Brainstem- quadriplegia, disturbance of gaze/ vision, locked in syndrome (basilar artery)
* Lacunar- Ataxic hemiparesis, pure motor or sensory, dysarthria, clumsy hand. Cognition intact.
31
Acute management of stroke
* ABCDE --\> stroke unit. NB airway.
* Pulse, BP, ECG - ?AF
* Blood glucose (aim 4-11)
* Urgent CT/MRI head. ??Haemorrhagic/ischaemic
* Thrombolysis- alteplase if ischaemic + \<4.5h. CI= Haemorrhage, major infarct, mild Sx, aneurys, BP \>220/130, severe liver disease, anticoagulation
* Aspirin 300mg for 2w --\> 75mg
* NBM until SALT assessed
32
Long term stroke management
* Rehab= MENDS
* MDT
* Eating- screen swallowing and malnutrition
* Neurorehab (physio + SALT)
* DVT prophylaxis
* Sores- AVOID
* Discharge medication:
* Atorvastatin
* ACEi
* Clopidogrel
* No driving at least 3 months. Inform DVLA
33
Stroke DDx
* Head injury
* High/ low glucose
* Subdural
* Tumour
* Hemiplegic migraine
* Epilepsy
* CNS lymphoma
* Wernicke's
* Drug OD
34
Ix RF for further stroke
* BP
* Cardiac source- ECG, CXR, ECHO
* Carotid artery stenosis- USS Doppler
* Glucose
* Lipids
* Vasculitis
* Prothrombotic states eg antiphospholipid
* Hyperviscosity eg sickle cell
* Genetic testing
35
Complications of stroke
* Aspiration pneumonia
* Pressure sores
* Contractures
* Constipation
* Depression
* Family stress/ pressure
36
Ix and Tx of TIA
* Ix: Find cause and define vascular risk!
* ABCDE
* Bedside- ECG
* Bloods- FBC, ESR, U+Es, glucose, lipids
* Imaging- Carotid USS dopler, CT, MRI, ECHO
* Tx:
* Conservative- improve RF, no driving 1month
* Medical- ACEi, statin, clopidogrel, aspirin
* Surgical- ?endarterectomy
* See specialist within 7 days!
* See specialist \<24h if 4 or more on ABCD2 score (Age \>60y, BP \>140/90), clinical features (weakness, speech disturbance), duration, diabetes
37
Features of venous sinus thrombosis
* Sx gradual
* Sagittal (most)- Headache, vomiting, seizures, reduced vision, papilloedema
* Transverse- Headache +/- mastoid pain, focal CNS signs, seizures, papilloedema
38
Features of cortical vein thrombosis
* Stroke like focal Sx that develop over days
* Sudden headache- thunderclap
* Signs- seizures (more common than stroke), encephalopathy, slowly evolving focal deficits
39
Features of acute glaucoma
* Headache- constant, aching pain. Develops rapidly and radiates to forehead.
* Loss of vision and visual haloes
* N+V
* Red congested eye, with cloudy cornea
* Dilated non-responsive pupil (may be oval)
* Precipitants- dilating eye drops, emotional upset, sitting in dark.
* Tx --\> specialist. Acetazolamide if delayed
40
Features and Tx of tension headache
* Headache- bilateral "tight band". Throbbing (not pulsatile). Can spread to neck/ back/ shoulders/ behind ears
* Other Sx- irritability, poor concentration, want to sleep. Able to do daily activities.
* RF- stress, anxiety, poor posture, tiredness, dehydration.
* Tx- paracetamol, ibuprofen (not \>6 times/ month)
41
Features of medication overuse headache
* Episodic --\> daily chronic
* Use analgesia 6d/month max!
42
Features of migraine
* RF: Female, obese, patent foramen ovale
* Triggers= CHOCOLATES: Chocolate, hangovers, OCP, Cheese, Orgasms, Lie ins, Alcohol, Tumult, Exercise, Stress
* Sx:
* Unilateral throbbing headache. 3-72h.
* Temporal/ frontal area
* Photo/phonophobia
* N+V
* Prodrome: yawning, cravings, mood/sleep change, aura (visual, parietal, frontal)
* Ix: headache diary
43
Diagnosis of Migraine
* Typical aura + headache
* OR \>4 headaches lasting 4-72h with N+V or photo/phonophobia + 2 or more of:
* Unilateral
* Pulsating
* Interferes with normal life
* Worsened by routine activity
44
Treatment of migraine
* Acute attack:
* Paracetamol + metoclopramid/ domperidone
* NSAIDs eg ketoprofen + M/D
* Triptan eg sumatriptan
* Ergotamine
* Prophylaxis
* ?\>2 attacks/ month, increasing frequency, ++disability, unable to take acute Tx
* Propranalol, topiramate
* Valproate, pizotofen (weight gain), gabapentin
45
Features and Tx of TMJ dysfunction
* Sx:
* Pain- ear, jaw temple
* Temporal headache/ earache
* Difficulty opening mouth
* Jaw locking
* Crepitus
* Clicking/ popping/ grinding when move jaw
* Tx:
* Conservative= mainstay. Eat soft foods, ice packs, massage, avoid gum and biting nails. Refer to dentist/ psychologist
* Med- Paracetamol/ ibuprofen, analgesia injections
* Surgergy- last resort
46
Features and Tx of cluster headache
* RF: FHx, male, smoker
* Sx:
* Rapid onset of excruciating headache around 1 eye. UNILATERAL.
* 15-160 mins
* Eye- watering, bloodshot, lid swelling, lacrimation, rhinorrhoea, miosis +/- ptosis
* Facial flushing
* Clusters 4-12w once-twice a day. Months remission between.
* Tx:
* Acute attack- 100% o2 for 15 mins via non-rebreath. Sumatriptan.
* Prevention- verapamil, lithium, melatonin
47
Features, Ix and Tx of trigeminal neuralgia
* Sx:
* Paroxysms of intense stabbing pain in trigeminal n. distribution (esp maxillary and mandibular). Secs. Face scrunches in pain.
* Triggers- washing, shaving, eating, talking, dental prostheses.
* Pt: Male \>50. More likely in Asian.
* Secondary cause in 14%- compression of CNV, MS, zoster --\> Ix = MRI
* Tx:
* Medicine- Carbamazepine, lamotrigine, phenytoin, gabapentin
* Surgical- microvascular decompensation
48
Features of GCA
* = Giant Cell Arteritis.
* Rule of 60: \>60y, ESR\> 60, pred 60mg
* Sx:
* Headache
* Temporal artery/ scalp tenderness (combing hair)
* Jaw claudication
* Amourosis fugax
* Sudden blindness
* Extracranial- SOB, morning stiffness, unequal pulses
49
Ix and Tx of GCA
* Ix:
* Bedside- Fundoscopy
* Bloods- ESR \>50, CRP (up), FBC (high platelets, normocytic normochromic anaemia), LFTs (high alk phos)
* Imaging + special- temporal artery USS/ biopsy
* Tx:
* Prednisolone 60mg/d PO ASAP!!!!
* Methyprednisolone IV if eye Sx
* Wean off steroids. NB PPI + bisphosphonates
* Low dose aspirin
* Prognosis- 2y --\> complete remission
50
Causes of seizures
* Epilepsy= recurrent seizures (\>2)
* Idiopathic = 2/3
* Structural- cortical scarring, head injury, developmental, SOL, stroke, vascular malformation
* Acquired- Sarcoid, SLE
* Non-epileptic/ provoked: Trauma, stroke, haemorrhage, raised ICP, CVA, alcohol, meningitis/ encephalitis, malaria, HTN/eclapsia, drugs (OD, antidepressants, tramadol, withdrawal- alcohol, opiates, BDZs), pyrexia, metabolic disturbance (hypocalcaemia, sodium, glucose, ureamia)
51
Seizure classification
52
Seizure classification
* Partial (1 hemisphere)
* Simple - aware
* Complex - Aura, ANS Sx, not aware, automatisms, amnesia
* Generalised (2 hemispheres)
* Tonic clonic- LOC, stiffening --\> jerking. Cyanosis, incontinence, tongue biting
* Absence- \<10s pauses.
* Atonic/ tonic= sudden loss of muscle tone. No LOC
* Myoclonic- sudden muscle jerks
53
Partial seizure localising features
* Occipital- visual
* Parietal- sensory
* Fronal- motor
* Temporal- automatisms, deja vu, delusions, emotional disturbance, aura
54
What are Stokes- Adams attacks?
Transient arrhythmias. Fall to ground, pale, absent pulse. Recovery in seconds --\> flushes and pulse increases. +/- clonic jerks
55
Features of PNES
* Psychiatric RF
* Gradual onset
* Non-stereotypical movements- pelvic thrusting, back arching, thrashing
56
Epilespy Ix
* Bedside- BM, ECG, urine tox, drug screen
* Bloods- FBC, U+Es, glucose, ?AED levels, lactate (up), prolactin 10 mins after fit (up).
* Imaging- MRI if focal onset, refractory to Tx, adult onset. (CT)
* Special- ?LP, EEG- supports Dx, ?focal/generalised
57
Epilepsy Tx
* Start after 2nd seizure. MDT approach.
* Conservative:
* Driving- inform DVLA, no driving 6-12m after 1st seizure. Need to be seizure free 1y.
* Education- swimming, bathing, 1st aid, avoid triggers, healthy lifestyle, min alcohol.
* Medical:
* Tonic-clonic: Sodium valproate --\> lamotrigine
* Absence: Sodium valproate/ ethosuxamide --\> lamotrigine
* Tonic/ atonic/ myoclonic: sodium valproate --\> levetiracetem
* Focal: Lamotrigine --\> carbamazepine
* Preg- lamotrigine, 5mg folic acid
* Surgical: ?resection if single lesion
58
When and how to stop AED?
* Consider when seizure free 2y
* Decrease 10% every 2-4w.
* 50% remain seizure free.
59
AED side effects
* Sodium valproate- teratogenicity, liver failure, tremor, weight gain
* Lamotrigine- Rash, diplopia, blurred vision
* Carbamazepine- Cerebellar toxicity, SIADH (--\> hyponatraemia)
* Phenytoin- Ataxia, tremor, hepatoxicity, gum hypertrophy
60
Definition of status epilepticus
* Seizure lasting \>30mins
* OR repeated seizures with no intervening consciousness.
* (New seizure if 30min between)
61
Status epilepticus management
* 0-5 mins:
* ABCDE. NB airway. 100% o2. Recovery position.
* Monitor: HR, o2, sats, BP, temp, heart tracing
* Venous access + bloods: FBC, U+Es, LFTs, Ca2+, glucose, cultures, ABG, ?AED
* ?CT
* Glucose \<3.5mmol/L --\> 100mL 20% glucose
* 5-20 mins: 5 mins = senior help!
* BDZ: Lorazepam 4mg IV over 2 mins OR Diazepam 10mg PR OR buccal midazolam. Repeat after 10 mins if needed.
* Pabrinex if alcoholic/ malnourished
* Tx acidosis
* 20-40 mins: NB anaethetist!
* Phenytoin 20mg/Kg IV at \<50mg/min
* Alt: diazepam infusion, phenebarbital
* \>40 mins: ICU. GA, intubation, EEG monitoring.
62
Causes of Parkinsonism
* Degenerative- PD, Parkinson's plus
* Infection- Syphilis, HIV, CJD
* Vascular- Infarcts to substantia nigra
* Drugs- Antipsychotics, metoclopramide
* Genetic- Wilson's
* Trauma eg boxing
63
Symptoms of Parkinsonism
* Triad of:
* Tremor- pill rolling. 4-6Hz.
* Bradykinesia/ hypokinesia. Slow initiation of movement, slow blink rate, micrographia.
* Ridigity- cog wheel, lead pipe
* Gait- less arm swing, shuffling
* Expressionless face
* Stooped posture
* Postural instability
64
Presentation of Parkinson's Disease
* Parkinsonism- tremor, ridigity, bradykinesia
* Stooped posture
* Shuffling gait
* Postural instability
* Neuropsychotic- depression, anxiety, depression
* Sensory- olfactory, pain, paraesthesia
* Fatigue
* Diplopia
* ANS- Bladder, sexual dysfunction, dry eyes, constipation
* Insomnia
65
Diagnosis of PD
* Bradykinesia
* At least 1 of: rigidity, 4-6Hz tremor, postural instability
* Exclude DDx- stroke, head injury, dementia, cerebellar signs
* DAT scan- retreating comma.
66
Tx of Parkinson's Disease
* MDT
* Assess disability with UPDRS
* Conservative- postural exercises
* Medical:
* Young/ fit: MAOi (selegeline/ rasagiline) or dopamine antagonist (rotigotine) --\> L-dopa/ COMTi (entacapone)
* Old/ frail: L-dopa (sinemet/ co-careldopa/ madopar) --\> MAOi/ COMTi
* Dyskinesia- reduce L-Dopa, add amantadine
* Motor fluctuations- duodopa
* Severe resistant tremor/ motor fluctuations --\> DBS
67
Side effects of PD medications
* L-Dopa: Tolerance, N+V, confusion, hallucination, dyskinesias
* Rotigotine: Lack of impulse control
* MAOi: Seratonin syndrome with SSRIs
* Amantadine: Confusion in elderly
68
Parkinson's Plus syndromes
* = Basal ganglia degeneration and other systems
* Lewy Body Dementia- Flutuating cognition, visual hallucinations, apathy, more day time sleep, poor attention
* Multiple systems atrophy- cerebellar signs
* Progressive supranuclear palsy- postural instability
* Corticobasilar degeneration- aphasia, dysarthria, apraxia
69
Definition and classification of MS
* Multiples episodes of CNS dysfunction dissemintated in time and space (2 diff eps in diff places of NS)
* Patterns:
* Relapsing-remitting (80%)
* Secondary progressive
* Primary progressive (10%)
* Progressive relapsing
70
Presentation of MS
* TEAM- tingling, eye, ataxia + cerebellar, motor
* Spastic weakness
* Sensory- paraesthesia, pain, trigeminal neuralgia
* Eyes- diplopia, nystagmus, optic neuritis (unilat central vision loss, pain on eye movements).
* CNS- fatigue, poor cognition, depression
* Sexual/ GU- ED, anorgasmia, retention, incontinence
* GI- swallowing probs, constipation
* Speech- dysarthria, dysphagia
* Cerebellar- trunk and limb ataxia, falls
71
MS Ix
* Bloods- B12, FBC, Abs- anti-MBP, NMO-IgG
* Imaging- MRI: Gd enhancing plaques
* Special:
* LP- oligoclonal bands of IgG
* Evoked potentials delayed
72
MS Tx
* Acute- Methylprednisolone 1g IV PO for 24h
* Disease modifying:
* Beta-interferons
* Monoclonal Abs- natalizumab, alemtuzumab
* ?Stem cells
* Symptomatic tx:
* Depression- SSRI
* Pain- amitriptylline, gabapentin
* Spasticity- physio, baclofen, botulinum
* Urgency/ frequency- oxybutinin
* Tremor- clonazepam
73
MS Complications
* Ambulation
* Spasticity
* Pressure sores
* UTIs
* Osteoporosis
* Aspiration pneumonia
* Epilepsy/ seizures
* Depression/ stress/ anxiety
74
What is Motor Neurone Disease?
* Progressive selective loss of neurones in motor cortex, cranial nerve nuclei and anterior horn cells. UMN + LMN signs.
* NO sensory loss, sphincter disturbance or affect on eye movement
* Types:
* ALS- UMN + LMN
* Progressive bulbar palsy
* Progressive muscular atrophy- LMN only
* Primary lateral sclerosis- mainly UMN
75
Presentation of MND
* \>40y
* Stumbling spastic gait
* UMN signs- Spasticicty, hyperreflexia, upgoing plantars
* LMN signs- Wasting, fasiculations
* Bulbar- speech/ swallow/ tongue fasiculations
* Fronto-temporal dementia
* Aspiration pneumonia
* Weakness- shoulder abduction, grip
* Foot drop/ proximal myopathy
76
Ix and Tx of MND
* Ix:
* EMG- denervation
* Imaging- brain/ cord MRI exclude structial cause eg SC compression
* Special- LP - exclude inflammatory
* Tx: MDT + family!
* Specific- Rilozole (prolongs life)
* Dysphagia- NG/PEG
* Resp failure- NIV
* Pain- analgesia ladder
* Spasticity- baclofen, botulinum
77
What is myaesthenia gravis and how does it present?
* AI disease against post-synaptic ACh receptors
* Presentation:
* Increasing/ relapsing muscular weakness. Muscle groups affected in order. Worsens with exercise
* 1. Ptosis, diplopia
* 2. Bulbar
* 3. Myaesthenic snarl
* 4. Head droop
* 5. Limb proximal weakness
* Normal reflexes
78
Ix and Tx of myaesthenia gravis
* Ix:
* Bedside- FVC
* Bloods- Anti-AChr Abs, TFTs
* Imaging- ?thymus CT
* Special- EMG (reduced response), tensilon test (improvement 1min)
* Tx:
* Sx- anticholinesterase
* Immunosuppression- Pred in acute, azathiprine, methotrexate
* Surg- thymectomy
79
Key features, presentation, Ix and Tx of Lambert Eaton syndrome
* Cause= AI or paraneoplastic. Abs against pre-synaptic Ca2+ channels
* Presentation: Leg weakness early, hyoreplexia and weakness that improves with exercise. Diplopia and resp muscle involvement rare.
* Ix: Anti-VGCC Abs
* Tx: IV immunoglobulins.
* Reg CXR + screening for lung Ca
80
Features and Ix of Brown- Sequard syndrome
* Lesion to 1/2 spinal cord
* Ipsilateral loss of proprioception + vibration. UMN weakness (spastic, brisk)
* Contralateral loss of pain and temperature
* Ix- MRI
81
What is Guillain barre syndrome and how does it present?
* = Acute AI demyelinating polyneuritis
* Triggers= campylobacter, CMV, VZV, HIV, EBV. FEW WEEKS POST INFECTIVE.
* Presentation:
* Symmetrical asceening flaccid paralysis
* LMN signs- areflexia, fasiculations
* Proximal \> distal. Esp trunk and resp muscles.
* Back pain
* Paraesthesia
* ANS neuropathy- arrhythmias, labile BP, sweating, unrinary retention
82
Ix and Tx of Guillain Barre
* Ix:
* Bedside- FVC, stool sample
* Bloods- antiganglioside Abs
* LP - increased protein
* Nerve conduction studies - slow
* Tx:
* Cons- physio
* Supportive- Airway (ventilation), Analagesia (NSAIDs, gabapentin), Autonomic (inotropes, catheter), Antithrombotic (TEDS, LMWH)
* IV immunoglobulins
83
What is muscular dystrophy and how might it present?
* Group of genetic diseases with progressive degeneration and weakness of specific muscle groups.
* Duchenne MD:
* Commonest. X-linked recessive. Non-functional dystrophin
* Presents around 4y. Difficulty standing, calf pseudohypertrophu, resp failure.
* Ix= CK. Tx: ?home ventilation
* BMD: Partially functioning dystrophin --\> presents later, less severe, better prognosis
84
Causes of spinal cord compression
* Trauma
* Infection
* Intrinsic cord tumour
* 20 to malignancy- breast, thyroid, lung, kidney, prostate
* Disc prolapse
* Haematoma
* Myeloma
85
Presentation of spinal cord compression
* Local radicular back pain at level of lesion, anaesthesia below
* LMN signs at level of lesion, UMN signs below.
* Bladder hesitancy/ frequency --\> retention
* Constipation/ faecal incontinence
* Reduced tone and reflexes in acute
86
Ix and Tx of spinal cord compression
* Ix:
* URGENT MRI - neuro surgery emergency
* Screening bloods- FBC, ESR, B12, syphilis, U+Es, LFTs, PSA, electrophoresis
* CXR- screen for primaries. ?biopsy
* Tx: Refer oncology + neurosurgery.
* Cons- catheter
* Cancer- dexamethasone 16mg OD IV. ?chemo/ **radio**
* Abscess- ABx
* **Surgical** decompression
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Signs of conus medullaris and cauda equina lesions
* Conus medullaris:
* Mixed UMN and LMN weakness
* Early constipation and retention
* Back pain, sacral sensory, ED
* Cauda equina:
* Saddle anaesthesia
* Back pain and radicular pain down legs
* Bilat. flaccid, areflexic lower limb weakness
* Incontinence, retention of faeces/ urine
* Poor anal tone
88
What is cervical spondylosis and cervical myelopathy?
* Cervical spondylosis= degeneration of cervical spine due to trauma/ aging (degen. of annulus fibrous) + bony spurs) --\> compression of SC and nerve roots --\> progressive quadriparesis + sensory loss below neck
* Degenerative cervical myelopathy= compression of cervical spinal cord from disc herniation or cervical spinal stenosis.
* DDx carpal tunnel!
89
Presentation of cervical spondylosis
* Most ASx
* Progressive
* Neck pain/ stiffness +/- crepitations
* Stabbing/ dull pain in arm
* Radiculopathy- pain/ electrical sensations in arms/ fingers at level. DDx carpal tunnel
* Upper limb motor/ sensory disturbance according to compression level
* Later- spastic quadriparesis, sphincter dysfunction (bladder/ bowel)
*
90
Ix, Tx and complications of cervical spondylosis
* Ix= MRI
* Tx:
* Conservative- stiff colar, analgesia
* Medical- steroid injections
* Surgical- decompression, laminectomy/ laminoplasty
* Complications= quadriplegia, diaphragm paralysis, spinal artery syndrome
91
What is carpal tunnel and how does it present?
* = Mononeuropathy. Compression of median nerve (C1-T1) - test= pincer grip
* Presentation:
* Sensory loss/ paraesthesia in thumb, index and middle fingers
* Wasting of thenar eminence
* Aching pain, esp at night
* Weakness of muscles of precision grip (LOAF)
* Tinel's- tap wrist
* Phalen's- wrist flexion 1 min
92
Ix and Tx of carpal tunnel
* Ix- neurophysiology
* Underlying cause? Myoedema, DM, idiopathic, acromegaly, neoplasm, RA, amyloidosis, pregnancy, sarcoid.
* Tx-
* Splint
* Steroid injections
* Surgical decompression
93
Features and Tx of ulnar nerve neuropathy
* C7-T1
* Presentation:
* Weakness/ wasting hypothenal eminence/ medial muscles/ 4th/5th digitis --\> test= abduction and adduction of fingers
* Claw hands
* Sensory loss medial 1.5 fingers
* Tx:
* Rest
* Elbow/ hand splint
* Surgical decompression, epicondylectomy, nerve re-routing
94
Radial nerve neuropathy
* C5-T1
* Motor- muscles that open fist of hand --\> test = extension of wrist and fingers
* Sensory loss in anatomical snuff box
95
Causes and features of brachial plexus neuropathy
* Causes- trauma, radiotherapy, heavy rucksack, cervical rib fracture, thoracic outlet compression
* Sx- pain, paraesthesia + weakness in arm
* Erb's palsy- tip the waiter
96
Phrenic nerve palsy
* C3,4,5 keep the diaphragm alive
* Sx- orthopnoea
* CXR- raised hemidiaphragm
* Causes- Cancer (lung, paraneoplastic), TB, MD
97
Features of sciatic nerve neuropathy
* L4, S1
* Affects hamstrings, muscle below knee --\> foot drop
* Loss of sensation below the knee
* Sciatica= lower back pain, shooting pain down leg. Ix- MRI. Tx- physio, physio, decompression
98
What is polyneuropathy and what might cause it?
* Motor and/or sensory disorders of multiple peripheral/ cranial nerves. Usually symmetrical, widespread. Often distal 'glove and stocking'.
* Causes:
* Infective- HIV, leprosy, Lymes', syphilis
* Inflammatory- Guillain-Barre, sarcoid
* Metabolic- DM, CKD, hypothyroid, hypoglycaemia, B12/ folate deficiency
* Vasculitis- PAN, GPA, RA
* Malignancy- Paraneoplastic, polycythaemia
* Inheritied- CMT, porphyria
* Drugs- Cisplatin, nitrofurantoin, metronidazole
99
What is vertigo?
* An illusion of movement, often rotatory, of patient or their surroundings.
* Worse on movement.
* Associated symptoms:
* Difficulty walking
* N+V
* Hearing loss/ tinnitus (labryth or CNVIII involvement)
* Pallor
* Sweating
100
Causes of vertigo
IMBALANCE
* Infection/ Injury- Labrynthitis, Ramsay Hunt, trauma
* Meniere's
* Benign positional vertigo
* Arterial- Migraine, TIA, CVA
* Lymph - perilymph fistula
* Aminoglycosides/ cisplatin/ furosemide- ototoxicity
* Nerve
* Central- MS, tumour, infarct
* Epilepsy
101
What is labrythitis?
* Vestibular neuronitis. Cause= viral, vascular
* Sx- abrupt onset of vertigo, N+V
* No deafness or tinnitus
* Tx- rest and reassurance. ?sedation
102
What is Ramsay Hunt syndrome? Treatment?
* Latent VZV
* --\> Painful vesicular rash in auditory canal with ipsilateral facial palsy, loss of taste, vertigo, tinnitus, deafness, dry mouth and eyes.
* Tx within 72h! Aciclovir, prednisolone
103
Features, Ix and Tx or Meniere's
* Meniere's = endolymphatic hydrops --\> recurrent attacks of vertigo \>20mins (+/- N+V), fluctuating sensorineural hearing loss + tinnitus.
* Sense of aural fullnes
* Tx:
* Acute- rest
* Prolonged- antihistamine
* Severe- buccal prochlorperazine
* Prevention- Betahistine
* Inform the DVLA! Drive when Sx under control
104
Features of Benign Positional Vertigo
* Canalithosis in semicircular canal
* Disturbs with head movement --\> vertigo for few seconds
* Dx= nystagmus on hallpike manoever
* Tx= Epley manoever
105
Features of perilymph fistula
* = Connection between inner and middle ear. Cause= congenital, trauma
* PC- vertigo, sensorineural hearing loss.
* O/E- Tullio's phenomenon- nystagmus evoked by loud sound
106
Features of acoustic neuroma
* = Schwannoma of vestibular nerve.
* Sx= unilateral hearing loss --\> vertigo.
* Progression --\> ipsilater CN and cerebellum
107
Causes of cranial SOL
* Vascular - chronic subdural haematoma, AVM, aneurysm
* Infection - abscess, cyst
* Neoplasm:
* Primary- astrocytoma, glioblastoma, meningioma, haemangioblastoma, CNS lymphoma, ependyoma etc
* Secondary- Breast, lung, melanoma
* DDx- CVA, head injury, encephalitis, MS, metabolic disturbance
108
Presentation, Ix and Tx of cranial SOL
* Presentation:
* Signs of raised ICP- headache, vomiting, papilloedema, low GCS
* Subtle change in personality
* Evolving focal neurology
* Seizure - esp adult onset, localising aura, post-ictal weakness (Todd's)
* Ix:
* CT/ MRI
* Biopsy
* Tx:
* Medical- pred, chemo, stereotactic radio, prophylactic phenytoin, analgesia
* Neurosurgery- debulking
*
109
Causes of Facial Palsy
* CNII palsy- Bell's, Ramsay hunt, lyme's, meningitis, TB, viruses
* Brainstem- stroke, tumour, MS
* Cerebella-pontine- acoustic neuroma, meningioma
* Systemic- DM, sarcoid, GB
* ENT- parotid tumour, otitis media
* Other- Trauma to base of skull, diving, intracranial hypotension
110
What is Bell's Palsy and how does it present?
* = Entrapment and inflammation of CNVII. Dx of exclusion. 70% facial palsy. Likely viral origin- HSV1
* Presentation:
* Suddon onset - overnight
* Complete unilateral facial palsy. Not forehead sparing (LMN). Can't close eye, drooling, speech difficulty
* Numbness/ pain around ear.
* Ageusia (loss of taste)
* Hypersensitivity to sound
111
Ix and Tx of facial palsy
* Ix:
* Bloods- glucose, ESR, VZV (ramsay hunt), borrelia Ab (lyme's)
* Imaging- MRI ?stroke/MS/SOL
* Special- LP- ?infection. Nerve conduction @2w
* Tx:
* Cons- protect eye (dark glasses, drops, tape)
* Med- pred within 72. 60mg PO for 5 days. Vasaciclovir if ?VZV
* Surgery- lid loading, botulinum toxin
* 80% full recovery
112
Features of CN3 palsy
* Sx- diplopia
* Signs- Eye down + out, ptosis, pupil dilation
113
Features of CN4 palsy
* Sx: neck pain
* Signs: Head tilt away from lesion. Eye in + up
114
Features of CN6 palsy
* Inward eye deviation. Inability to look out.
115
Types/ causes of tremor
RAPID
* Resting- 6-12Hz, pill rolling. Improves with distraction. Cause= Parkinsonism.
* Action/ Postural- 6-12Hz. Absent at rest. worse with movement. Causes= BEATS
* Benign essential tremor - arms/neck/voice
* Endocrine- hyperthyroid, hypo, phaeo
* Alcohol/ caffeine/ opioid withdrawal
* Toxins - beta-agonists, valproate
* Sympathetic - anxiety increases tremor
* Intention- Large amplitude. Worse at endo of movement --\> past pointing. Cause= cerebellar
* Dystonic
116
What is chorea and what causes it? Tx?
* Chorea= "dance". Non-rhythmic, purposeless, jerky movements
* Causes:
* BG- stroke, Huntington's
* Sydenham's- streptococci (rheumatic fever)
* SLE
* Wilson's
* Neonatal kernicterus
* Polycythaemia
* Hyperthyroid
* Drugs- L-dopa, OCP, HRT, chlorpromazine, cocaine
* Tx= Dopamine agonists
117
What is dystonia and what causes it?
* = Prolonged muscle contracture --\> unusual joint position/ repetitive movements
* Idiopathic generalised/ focal dystonia. General= autonomic dominant, onset children. Focal= most common. 1 part of body, worse with stress.
* Acute dystonia- torticollis, trismus, occulogyric crisis. Typically drug reaction- neuroleptics, metocloramide, L-dopa --\> Tx= procyclidine
118
Back pain DDx
* Cord compression
* Cauda Equina
* Spinal mets
* Myeloma
* Vertebral collapse fracture
* Aortic aneurysm
* Infection
* Renal colic
* Mechanical- sprain, disc prolapse, spondylosis, lumbar spine stenosis
* Pregnancy
119
Features, Ix and Tx of mechanical back pain
* Lower back pain. Worse on movement/ coughing
* Normal sensation and tone on PR
* Radiculpathic pain/ numbness
* May radiate to leg
* Tender around vertebrae
* Pain on straight leg raise
* Ix- usually none
* Tx:
* Cons- early mobilisation, hot/cold packs, posture, swimming/ walking, physio
* Med- analgesia, diazepam for muscular spasm, facet join injection
* Surg- ?decompression
120
Back pain red flags
* Age \<20 or \>55y
* Weight loss
* Fever, night sweats
* Night pain/ worse on rest
* Thoracic pain
* Hx of cancer
* Recent trauma
* Recent steroids
* Serious infection
* O/E- hyperreflexia/clonus
* Limb weakness/ paraesthesia
* Urinary/ bowel retention/ incontinence
* Constant/ progressive pain
121
Ix of back with red flags
* Bloods- FBC, ESR, CRP, ALP, PSA, serum electrophoresis, Ca2+
* Imaging- MRI, spinal x-ray, CXR, DEXA
* REFER TO NEUROSURGERY IF NEUROLOGY PRESENT
122
What nerve is damaged with a Seargent's Patch and how might this happen?
* Axillary nerve
* Due to shoulder dislocation
